I am a Jefferson-style independent (see the Nolan Chart) and I work in the field of health care. So nice try on the "Republican" label.

I can be considered an expert on the matter of health care financing, as I am a published health services researcher. So when you start quoting sources like Business Week, I can call "bullsheet" in a New York second. To wit...

That's a flat-out stupid statement. Managed care is supposed to keep people out of the hospital. Hospitals are where costs hemorrhage and people die from nosocomial infections.

Business Week wrote:

From 2010 to 2019, Obamacare trims payments to providers by $196 billion.

Did you not read what I wrote?

CMS Medicare fees to physicians were already too low. The RBRVS conversion factor is lower than what is paid by commercial insurance companies to doctors in their networks. Most doctors accepted the lower CMS payments because it kept the lights on and doors open (a loss leader). Lowering the conversion factor even more creates a situation where fees don't cover their costs. Thus many providers now are choosing not to accept Medicare patients.

Business Week wrote:

They agreed to take a cut because they will get so many new patients, thanks to the individual mandate.

That's right, Glenn. Stop taking Medicare patients and see only Commercial patients where you get a higher fee. What's not to like about that? Screw granny. Let her die and we all save money.

Business Week wrote:

Another $210 billion will be generated by raising Medicare taxes on the wealthy (that’s households earning more than $250,000).

... which they won't get back because Medicare won't cover them. They'll take on richer (Medicare Advantage) benefits. Thanks for nothing, Obama.

Business Week wrote:

Another $145 billion comes from phasing out overpayments to Medicare Advantage.

Overpayments to Medicare Advantage is an oxymoron. Commercial insurers do it better/cheaper than Uncle Sam. So Uncle Sam is overpaying them by giving them a risk-adjusted payment* equivalent to what CMS pays in traditional Medicare? Oooo... How damning!! Let's get rid of Medicare and let Commercial Insurers do all of it.

Business Week wrote:

More savings come from streamlining administrative costs.

Completely unproven. I've seen the research on things like Electronic Health Records. They generate as much costs as they save.

- Bill

* I worked for the company that designed the software that calculates relative risk scores for Medicare members. CMS uses these models to calculate risk-adjusted payments for Medicare Advantage members. It's designed so that the payment for an "average" Medicare member (relative risk score = 1.0) is the equivalent of what CMS pays for that member in Medicare. Commercial insurers are allowed to play, and they make money by doing it cheaper/better. And that ain't hard to do.

For "an expert on the matter of health care financing" and someone "who does multidimensional modeling on a daily basis", you sure are relying on unsupported anecdotes lately. Laugh at an article from the centrist Businessweek quoting analysis from the conservative Brookings Institute if you want, but at least it is something. And for a "Jefferson-style independent" you sure do repeat Republican inaccuracies enough.

For "an expert on the matter of health care financing" and someone "who does multidimensional modeling on a daily basis", you sure are relying on unsupported anecdotes lately.

Examples please?

Glenn wrote:

Laugh at an article from the centrist Businessweek

Not peer reviewed.

I've been a professional in the field for 20 years now. It doesn't take me long to find flaws in articles written on the subject. And for what it's worth, peer review is part of my job.

Glenn wrote:

quoting analysis from the conservative Brookings Institute

I'm proud of you, Glenn!

But truth is truth. And anything not peer-reviewed needs to be treated with great scrutiny - including my own writings.

That said I think that having help design an updated (newer and more granular) version of the risk models that CMS uses to pay Medicare Advantage plans does give me an inside track on the subject. I know that sounds obnoxious, but facts are facts. I also worked with the VP of Corporate Medical Policy at a major BCBS plan to change their fee schedule to the CMS-like RBRVS payment system. So I know a bit about that method of payment (fee for service) as well.

Seriously, after all these years of debates on this forum using public sources now all of a sudden we are restricted to peer-reviewed sources?!?! Peer-review is my professional world as well, but I do not expect it to play much of a role on a forum such as this. Besides, as far as the Romney/Ryan claim that "Obama stole over $700 billion from medicare", I doubt anything peer-reviewed exists. Think tanks like the Brookings Institute are probably as close as we'll get, at least until you get your analysis of it published in a peer-reviewed journal.

On a different note, does your work incorporate geographical/spatial modeling at all? I am always curious as to where it gets used in the private sector.

Obamacare adds to the administrative work needed to keep a doctor's office within regs. That's more hours, more cost, and possibly even another administrative employee needed.

Jason

In the last month I've gotten nearly nightly calls from my wife - a health care provider - about how her job has turned to a nightmare due to the consolidation of health care practices and increased use of Electronic Health Records as a response to the upcoming Obamacare. She comes home at 10 or 11 every night now, having to stay in the office and do work 5 to 6 hours after her last patient has left. And she's not getting more money for it.

She hasn't seen your post, but I know would tearfully thank you for being one of the rare who understand how bad it has gotten.

This site is the culmination of decades of research pioneered by John Wennberg on how medical resources are distributed in the United States, and how that affects utilization, quality, and outcomes. I wish I could post more here, but my work is all about giving my company a competitive advantage over others in the Medicare Advantage space. That's the way it works. CMS rewards health plans to the tune of $$$$ based on how they perform with respect to their peers.

I understand the confidentiality Bill, thanks for sharing what you could.

I don't see much of the impact of Electronic Medical Records, but I do know that my family general practitioner (of over 20 years) grumbles about now having to carry a laptop with him all day long from patient room to patient room. But wasn't the adoption of EMR inevitable with or without the new health care act? The initiative started long before Obama was first elected and reportedly over a third of doctor's offices were using it before Obama took office. How has the new act changed this trend?

I don't see much of the impact of Electronic Medical Records, but I do know that my family general practitioner (of over 20 years) grumbles about now having to carry a laptop with him all day long from patient room to patient room.

Welcome to the new world of health care. Paper is out; digital files are in.

I sometimes wonder how much these laptops now carry infection from place to place. It's not like you can throw them in the sink or the autoclave. At some point this interface technology will need to be changed.

Glenn wrote:

But wasn't the adoption of EMR inevitable with or without the new health care act? The initiative started long before Obama was first elected and reportedly over a third of doctor's offices were using it before Obama took office. How has the new act changed this trend?

EHR have been used in isolated settings before Obamacare. The technology has been there for a while. Obamacare creates incentives to speed up the penetration and adoption. And it also results in a windfall for certain companies that have developed these systems and needed adoption to turn a profit on their investments. One of the reasons certain companies (e.g. GE) lobbied heavily for Obamacare is because of what they got out of it in return.

As for how it all shakes out, well that's to be determined.

In a perfect world, I don't have to mine financial transaction data to study who did what to which patient in what setting. I could instead mine the EHR data to get information right at the point-of-care source. I could get it in a more timely fashion rather than have to wait for all the billing information which can take around 3 months to settle. So when we're trying to improve care for a cohort of people with a particular chronic condition with a new intervention, we don't have to wait so long to figure out if it's working. Now that can sort of work in a staff model HMO setting like Kaiser where they own the docs and the systems they work with. But in independent physician, hospital, pharmacy, imaging, lab, and outpatient therapy settings from one end of the spectrum to the next, we just have to wait for the bills to come in before we know what happened to the covered members.

In that same perfect world, we could be sending *timely* information to the docs about what tests have or have not been done on people with chronic diseases so that we can get the checklist taken care of whenever you're able to get the patient to walk in the front door. But when it takes so long for information to travel through this fragmented system, the doc is often far behind what's going on.

You can create incentives to have EHR and everyone can adopt them. But that doesn't mean that the systems will be compatible with each other and information will travel through the system with speed. In fact privacy rules prevent all that from happening in many instances. That's good and bad at the same time.

So at the end of the day we can do the same thing with better technology, and not necessarily improve health care or make it less expensive. Assumptions were made about how all of this would create efficiencies in the system and lower costs. The problem is, nobody has proven that to be the case.

In the last month I've gotten nearly nightly calls from my wife - a health care provider - about how her job has turned to a nightmare due to the consolidation of health care practices and increased use of Electronic Health Records as a response to the upcoming Obamacare. She comes home at 10 or 11 every night now, having to stay in the office and do work 5 to 6 hours after her last patient has left. And she's not getting more money for it.

She hasn't seen your post, but I know would tearfully thank you for being one of the rare who understand how bad it has gotten.

- Bill

Bill,

Military healthcare providers have been dealing with electronic health records for the last decade and a half. Our ER docs have so far dodged that bullet, but yeah, the clinics are consumed by it. Docs can try to whittle away at some of it during a patient's appointment, but it can take their attention away from the patient, and that is a bad thing. Electronic records don't simply let you jot a note like paper records do. Everything has to go under a different option, followed by another sub-option, and so forth. A great many points and clicks, and eventually you get to where you need to type something, and then it's on to more points and clicks. It's time-consuming to say the least. We have providers who come in on Saturday to finish up the week's charts. Your wife has my sympathy, and I dread the day I have to go back to that.

I still have not heard any answer to the question that will bury Obamacare: where will we get the doctors who will see all these people entering the healthcare system, when we were already facing a shortage of physicians? Especially when we are making it an ugly prospect to be a physician in the first place?

I still have not heard any answer to the question that will bury Obamacare: where will we get the doctors who will see all these people entering the healthcare system, when we were already facing a shortage of physicians? Especially when we are making it an ugly prospect to be a physician in the first place?

The major deficit will be in primary care. It was lacking before a law was signed that will throw 30 million people into the system. This is *the* most important branch of medicine, and pays the least. Once a patient leaves primary care and ends up in specialty care, the coordination/continuity deteriorates and the dollars start hemorrhaging.

There aren't enough slots available in medical schools to grow new ones. There aren't the residency programs in medical centers to train them on the job after school. And there isn't the financial incentive to draw large numbers of people into it. And Obamacare did NOT solve the problem of a$$hole trial lawyers sucking dollars out of people who do real work. If anything, a program constructed by lawyers will just produce more money for lawyers.

Now if only they eliminated slots in law schools, and gave them all to the medical schools...

So here are the solutions I see:

1) We import primary care physicians from doctors trained in other countries. It'll be like calling a help desk and getting someone from Mumbai on the other end of the phone. What could go wrong here?

2) Nurse practitioners and physicians assistants will get "battlefield promotions" to deliver care like full-fledged MD PCPs. And that won't be all bad. But given that their salaries won't cover malpractice premiums (much less afford them a living after paying said premiums), well we'll need "regime change" to perhaps give them special dispensation against the law offices of Dewey, Chetham, and Howe.

Just my opinion - worth what you paid for it. We'll see if I am right.

In the military, we already have PAs and NPs as PCMs. We led the way in electronic medical records, and I'm sure we're going to find ourselves leading in this trend.

This all works in the military because...

Military personnel are basically healthy until shot at or blown up. Only the healthy are allowed to sign up. Their diets are controlled and they are *made* to keep in shape. So primary care is relatively simple (mostly immunizing the sheet out of them) and trauma care is about stabilizing them until the patient can be gotten to surgery....

There are no a$$hole lawyers sucking money out of the system....

Electronic Health Records are a must where someone can be ANYWHERE in the world and suddenly need trauma care. You want all the patient's records available stat at any point in the world.

Translate that into a more fragmented, IPO-oriented health care system where you don't get to pick and choose whatever unhealthy, undisciplined patient walks in the front door, and you have issues.

That is kinda my question on just that one section--what happens if the claimed savings don't show up? What if streamlining does not result in the cost-savings they claim?People keep saying it but what if it doesn't show the "on paper" results?

Think about the vast $$$$$$ we lose in waste, fraud and abuse in Medicare/Medicade. You would think that since we know such widespread waste, fraud and abuse goes on we can fix it---but it has been going on for decades with no end in sight. If you can't even rein in waste, fraud and abuse--then how can people so blithely simply hope that you are actually going to get goverment to streamline?

Look at how many regulations you have to navigate just to produce and serve a hamburger.

Lots of claims are made "on paper" that never seem to work out in practice. Romany-care "worked" in a rich State with (as I recall) one of the highest physican to patiant ratios in the nation, with a pretty small population. So of course it would work if applied to 300+ million people.

Then again "we have to pass this bill before we can find out what is in it, away from the fog.........." still has her job. If that does not give you pause about the how the Left operates, what they are willing to inflict on people and the chances of getting things to work efficently--litterally sight unseen, then I don't know what might.

Military personnel bring with them dependents that pretty much line up with the outside population. You're absolutely right about the lawyers, though. Lawsuits are rare. I'm with you on the consequences of adopting this system for the public. Here's hoping the general public doesn't end up with 'free' healthcare. This system gets used and abused on that score.

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